Quality-of-care indicators among remote-dwelling hemodialysis patients: a cohort study

Abstract

Background: We hypothesized that the higher mortality for hemodialysis patients who live farther from the closest attending nephrologist compared with patients living closer might be due to lower quality of care.

Study design: Population-based longitudinal study.

Setting & participants: All adult maintenance hemodialysis patients with measurements of quality-of-care indicators initiating hemodialysis therapy between January 2001 and June 2010 in Northern Alberta, Canada.

Predictors: Hemodialysis patients were classified into categories based on the distance by road from their residence to the closest nephrologist: ≤50 (referent), 50.1-150, 150.1-300, and >300 km.

Outcomes: Quality-of-care indicators were based on published guidelines.

Measurements: Quality-of-care indicators at 90 days following initiation of hemodialysis therapy and, in a secondary analysis, at 1 year.

Results: Measurements were available for 1,784 patients. At baseline, the proportions of patients residing in each category were 69% for ≤50 km to closest nephrologist; 17%, 50.1-150 km; 7%, 150.1-300 km; and 7%, >300 km. Those who lived farther away from the closest nephrologist were less likely to have seen a nephrologist 90 days prior to the initiation of hemodialysis therapy (P for trend = 0.008) and were less likely to receive Kt/V of 1.2 (adjusted OR, 0.50; 95% CI, 0.30-0.84; P for trend = 0.01). Remote location also was associated with suboptimal levels of phosphate control (P for trend = 0.005). There were no differences in the prevalence of arteriovenous fistulas or grafts or hemoglobin levels across distance categories.

Limitations: Registry data with limited data for non-guideline-based quality indicators.

Conclusions: Although several quality-of-care indicators were less common in remote-dwelling hemodialysis patients, these differences do not appear sufficient to explain the previously noted disparities in clinical outcomes by residence location.

Keywords: Hemodialysis; mortality; quality of care; residence location.